What are the treatment options for Meniere's disease?

Treatment for Ménière's Disease

Begin with dietary modifications (sodium restriction to 1500-2300 mg/day, limiting caffeine and alcohol) combined with patient education, then escalate to diuretics or betahistine for maintenance therapy, reserving intratympanic steroids for patients who fail non-invasive treatment, and consider intratympanic gentamicin or surgery only for refractory cases. 1, 2

Initial Management: Lifestyle and Dietary Modifications

Start all patients with sodium restriction to 1500-2300 mg daily to reduce endolymphatic fluid accumulation. 1, 2 This is the cornerstone of first-line therapy despite limited RCT evidence, as the American Academy of Otolaryngology-Head and Neck Surgery endorses this approach based on observational data and physiologic rationale. 1

• Limit caffeine intake, as it may trigger attacks in susceptible patients. 1, 2
• Restrict alcohol consumption, which can precipitate vertigo episodes. 1, 2, 3
• Have patients maintain a symptom diary to identify personal triggers. 2
• Address allergies if present, as they contribute to symptoms in up to 30% of patients. 1, 2
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep. 2

Critical caveat: While dietary modifications are widely recommended, a 2023 Cochrane review found very low certainty evidence for their effectiveness, with no placebo-controlled RCTs specifically for salt or caffeine restriction. 4 However, the low risk and potential benefit justify their use as initial therapy. 1

Patient Education (Essential Component)

Educate all patients about the natural history, symptom control measures, treatment options, and realistic outcomes. 1, 2 This is a strong recommendation based on RCT evidence showing improved quality of life and symptom control through patient empowerment and shared decision-making. 1

• Emphasize that no definitive cure exists, but symptoms can be managed. 2
• Explain that hearing loss may progress despite treatment interventions. 5

Acute Vertigo Attack Management

Prescribe a limited course of vestibular suppressants only during active vertigo attacks, not for continuous use. 1, 2 This prevents impaired vestibular compensation that occurs with chronic suppression. 1

• Use antihistamines (meclizine, dimenhydrinate) for acute symptom relief. 2
• Consider benzodiazepines for severe anxiety during attacks, but use cautiously due to dependence risk. 2
• Do not use vestibular suppressants between attacks, as they delay central compensation. 1

Maintenance Pharmacotherapy (Second-Line)

Offer diuretics and/or betahistine for maintenance therapy to reduce attack frequency. 1, 2 This is an option-level recommendation based on observational studies and Cochrane reviews showing moderate evidence quality. 1, 2

• Diuretics modify electrolyte balance in the endolymph and reduce its volume. 2, 6
• Betahistine (16-48 mg daily in divided doses) increases vasodilation to the inner ear. 2, 6

Important limitation: Recent evidence including the BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks, making the evidence for betahistine questionable. 2 Despite this, it remains an option given its favorable safety profile. 1

• Exclude patients with renal or cardiac disease before prescribing diuretics. 1
• Monitor for hyponatremia with sodium restriction plus diuretics, though this has not been reported in studies. 1

Intratympanic Steroid Therapy (Third-Line)

Offer intratympanic steroids to patients with active Ménière's disease not responsive to non-invasive treatment. 1, 2 This is supported by systematic reviews and RCTs showing 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy. 2

Benefits include:

• Improved vertigo control and quality of life. 1
• Faster return to work. 1, 2
• Avoidance of general anesthesia and lower hearing loss risk compared to surgical labyrinthectomy. 1

Risks include:

• Hearing loss (though less than ablative procedures). 1, 2
• Tympanic membrane perforation. 1, 2
• Persistent imbalance. 1
• Need for multiple treatments. 1

Intratympanic Gentamicin (Fourth-Line)

Offer intratympanic gentamicin to patients with persistent vertigo who have failed conservative therapies. 2 This achieves complete vertigo control in approximately 73.6% of patients across studies. 2

• Major risk: Hearing loss varies by administration method and dosing protocol. 2
• Reserve for patients willing to accept potential hearing sacrifice for vertigo control. 2
• Contraindicated in patients with contralateral disease or hypofunction. 1

Vestibular Rehabilitation

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy, but not during acute attacks. 2 This improves symptom control and reduces fall risk. 2

Surgical Options (Last Resort)

Consider surgery only for refractory cases after medical management failure:

• Endolymphatic sac decompression: Hearing-sparing procedure that may stabilize hearing. 5
• Vestibular nerve section: Hearing-sparing procedure for vertigo control. 5
• Labyrinthectomy: Ablative procedure for patients with non-usable hearing and intractable vertigo. 2, 5

Treatments NOT Recommended

Do not prescribe positive pressure therapy (Meniett device) for Ménière's disease. 1, 2 This is a strong recommendation against use based on systematic reviews and RCTs showing no significant difference compared to placebo. 1, 2

Monitoring and Follow-Up

Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention. 2, 5

• Obtain serial audiograms to monitor hearing progression. 5
• Assess quality of life impact regularly. 2, 5
• Adjust treatment based on symptom evolution. 2

Critical Pitfalls to Avoid

• Do not use vestibular suppressants chronically, as they impair central compensation and worsen long-term balance. 1
• Do not delay escalation in patients with frequent, disabling attacks, as hearing loss may progress irreversibly. 5
• Do not overlook bilateral involvement, which occurs in 25-40% of cases and affects treatment decisions. 6
• Do not promise hearing restoration, as current treatments cannot reverse established sensorineural hearing loss. 5